Annie Dubuisson

Brachial Plexus Injury: A Survey of 100 Consecutive Cases from a Single Service

OBJECTIVE We analyzed the epidemiology, preoperative management, operative findings, operative treatment, and postoperative results in a group of 99 patients who sustained 100 injuries to the brachial plexus. METHODS The charts of 100 consecutive surgical patients with brachial plexus injuries were reviewed. RESULTS The patient group comprised 80 males and 19 females ranging from 5 to 70 years of age. One male patient had bilateral brachial plexus palsy. Causes of injury were largely sudden displacement of head, neck, and shoulder and included 27 motorcycle accidents. There were 23 open wounds, including 8 gunshot wounds, 6 other penetrating wounds, and 9 wounds caused by operative or iatrogenic trauma. Loss was exhibited at C5–C6 in 19 patients, at C5–C7 in 15 patients, and at C5–T1 in 39 patients, and 8 patients had another spinal root pattern of injury. Nineteen patients had injury at the cord or the cord to nerve level. Associated major trauma was present in 59 patients. Emergency surgery for vessel or nerve repair was necessary in 18 patients. Myelography (n = 57) or magnetic resonance imaging (n = 7) revealed at least one root abnormality in 52 patients. The median interval from trauma to operation was 7 months. Operative exposures used included anterior supraclavicular, infraclavicular, combined supra- and infraclavicular, or a posterior approach in 5, 14, 77, and 4 patients, respectively. The surgical procedures performed included neurolysis alone in 12 patients and nerve grafting, end-to-end anastomosis, and/or neurotization in 81, 5, and 47 patients, respectively. Postoperative follow-up of at least 36 months was conducted in 78% of the patients. Grade 3 recovery according to Louisiana State University Medical Center criteria means contraction of proximal muscles against some resistance and of distal muscles against at least gravity. Among the 18 patients with open wounds, 14 (78%) recovered to a Grade 3 or better level, as did 35 (58%) of 60 patients with stretch injuries. In all cases of C5–C6 stretch injuries repaired by nerve grafting (n = 10), the patients recovered useful arm function. CONCLUSION Brachial plexus injury represents a severe, difficult-to-handle traumatic event. The incidence of such injuries and the indications for surgery have increased during recent years. Graft repair and neurotization procedures play an important role in the treatment of patients with such injuries.

Classical pituitary tumour apoplexy: Clinical features, management and outcomes in a series of 24 patients

We retrospectively analysed the incidence, clinical presentation, endocrinological and radiological findings, medical and surgical management of pituitary apoplexy in our department (single-centre study), having a large experience in pituitary surgery. Among 1540 pituitary lesions, 24 patients presented with pituitary apoplexy. Their charts were retrospectively reviewed. The symptoms included headache (92%), nausea and vomiting (54%), visual deficit (50%), oculomotor paresis (54%) and/or an altered mental state (42%). Skull X-rays (n = 14) demonstrated an enlarged sella turcica in all cases; CT-scan and/or MRI always revealed a sellar and suprasellar expanding lesion. Panhypopituitarism was present on admission in 70% of the patients. Urgent therapeutic management included high-dose cortisone treatment in all but one patients and CSF drainage in three. Three patients were treated conservatively. Nine patients were operated on rapidly, within hours or a few days because of severe visual deficit and/or altered level of consciousness. Nineteen patients were operated by the trans-sphenoidal approach; one of them required a second operation by craniotomy. There were two deaths related to the illness and one to an ill-defined reason at 4 months. Among the other patients 95% made a good recovery. All but two patients required a substitutive treatment with adrenal (83%), thyroid (68%), gonadal (42%) and/or growth (16%) hormones. The preoperative visual deficits recovered in all but one patients (92%) whereas the oculomotor pareses improved in all but two patients (85%). In conclusion, pituitary tumour apoplexy is a rare event, complicating in our series 1.6% of 1540 pituitary adenomas. Even in severe cases, complete recovery is possible if the diagnosis is rapidly obtained and adequate management is initiated in time. Surgical results after trans-sphenoidal approach are in the majority of cases very satisfactory.

Surgical management of anterior cranial base fractures with cerebrospinal fluid fistulae: a single-institution experience.

OBJECTIVEnThe management of cerebrospinal fluid (CSF) fistulae after anterior cranial base fracture remains a surgical challenge. We reviewed our results in the repair of CSF fistulae complicating multiple anterior cranial base fractures via a combined intracranial extradural and intradural approach and describe a treatment algorithm derived from this experience.nnnMETHODSnWe retrospectively reviewed the files of 209 patients with an anterior cranial base fracture complicated by a CSF fistula who were admitted between 1980 and 2003 to Liège State University Hospital. Among those patients, 109 had a persistent CSF leak or radiological signs of an unhealed dural tear. All underwent the same surgical procedure, with combined extradural and intradural closure of the dural tear.nnnRESULTSnOf the 109 patients, 98 patients (90%) were cured after the first operation. Persistent postoperative CSF rhinorrhea occurred in 11 patients (10%), necessitating an early complementary surgery via a transsphenoidal approach (7 patients) or a second-look intracranial approach (4 patients). No postoperative neurological deterioration attributable to increasing frontocerebral edema occurred. During the mean follow-up period of 36 months, recurrence of CSF fistula was observed in five patients and required an additional surgical repair procedure.nnnCONCLUSIONnThe closure of CSF fistulae after an anterior cranial base fracture via a combined intracranial extradural and intradural approach, which allows the visualization and repair of the entire anterior base, is safe and effective. It is essentially indicated for patients with extensive bone defects in the cranial base, multiple fractures of the ethmoid bone and the posterior wall of the frontal sinus, cranial nerve involvement, associated lesions necessitating surgery such as intracranial hematomas, and post-traumatic intracranial infection. Rhinorrhea caused by a precisely located small tear may be treated with endoscopy.

Sciatic Nerve Regeneration through Venous or Nervous Grafts in the Rat

This study analyses the interest of isologous venous grafts filled with saline or with Schwann cells versus nerve grafts as guides for regeneration of the sciatic nerve in 35 Wistar rats. Electrophysiological parameters (conduction velocities and distal latencies of motor responses) and the functional index of De Medinacelli were measured several times from 1 month to 1 year after surgery. An histological analysis was performed on 2 control rats and on 3 rats killed 6 or 12 months after surgery: the total number of fibers was counted on a montage photoprint of the whole nerve, and the diameters of axons and the thickness of the myelin sheath were measured on digitized images. With a portion of nerve as guide, the regeneration is faster than with a vein. However, regeneration after 6 months is at least as good with a venous graft filled with Schwann cells, as assessed by electrophysiological, functional, and histological analysis. The addition of Schwann cells in grafted veins allows the nerve to regenerate through longer gaps than previously described (25 vs 15 mm). In order to assess the quality of nerve regeneration, functional, electrophysiological, and histological analysis are complementary.

Intrasellar arachnoid cysts.

OBJECTIVETo evaluate the clinical, endocrinological, and radiological presentation of nine cases of surgically verified intrasellar arachnoid cysts and to discuss the physiopathological mechanisms of formation of these cysts. METHODSAmong 1540 patients presenting with pituitary lesions, nine presented with an intrasellar arachnoid cyst. Their charts were retrospectively reviewed. RESULTSPresenting symptoms included headache (n = 2), visual symptoms (n = 3), menstrual irregularities (n = 2), rapid weight gain (n = 1), vertigo (n = 1), and/or confusion (n = 1). Two cysts were discovered incidentally. T1-weighted magnetic resonance imaging scans showed an intrasellar cystic lesion in all cases, with a huge suprasellar extension in six cases. The cyst was of the same intensity as the cerebrospinal fluid (CSF) in only two patients. A transsphenoidal approach allowed the transdural aspiration of fluid and injection of a water-soluble contrast agent under mild pressure. In three patients, the contrast infiltrated along the pituitary stalk toward the subarachnoid spaces; in the other patients, it remained in the intrasellar compartment. Cyst membranes were removed as completely as possible with fenestration toward the subarachnoid spaces in communicating cysts. In spite of tight packing of the sella and sphenoid sinus, CSF fistulae requiring reoperation developed in two patients. CONCLUSIONThe clinical picture of an intrasellar arachnoid cyst resembles that of a nonfunctional pituitary adenoma. Magnetic resonance imaging scans typically show a cystic intrasellar lesion with suprasellar extension, containing isointense or, more often, hyperintense fluid on T1-weighted sequences. In spite of the risk of CSF fistulae, the preferred surgical approach is transsphenoidal. A physiopathological mechanism is proposed according to anatomic variations of the sellar diaphragma allowing penetration of subarachnoid spaces into the sellar compartment and their enlargement by a ball-valve mechanism.

Primary central nervous system lymphoma - Report of 32 cases and review of the literature

We retrospectively analyzed 32 cases of primary central nervous system lymphoma (PCNSL). Five cases were diagnosed in the period 1987-1994, for 27 cases in the period 1995-2002. There were 17 men and 15 women whose median age was 69 years. Three patients were immunodeficient. The commonest symptoms were focal deficit (16 patients) and cognitive/behaviour disturbances (14 patients). Radiologically, a total of 47 contrast-enhancing lesions were observed in 32 patients; 18 patients had deep-seated lesions. All but two patients underwent histological diagnosis following craniotomy (11 patients) and/or stereotaxic biopsy (22 patients); diagnosis was obtained on CSF cytology in one patient with a third ventricle tumour. In the last patient, the diagnosis was based on the finding of marked tumour shrinkage under corticotherapy, despite two negative histological examinations. Treatment included surgical resection (10 patients), chemotherapy (25 patients) and/or radiotherapy (12 patients). According to the therapeutic recommendations of the GELA (Groupe dEtude des Lymphomes de lAdulte), 19 patients received at least two courses of high-dose methotrexate; intrathecal chemotherapy was used in 20 patients with methotrexate and/or cytosine arabinoside. Radiation therapy consisted of whole brain irradiation followed by a boost on tumour site. Nine patients received a combined treatment of chemotherapy and radiotherapy. Twelve patients showed rapid progression to death. At the time of last contact, 28/32 patients (88%) had died, all from PCNSL disease or from complications due to its treatment. The median survival time was 13.9 months. We conclude that PCNSL is an increasingly frequent tumour. The diagnosis is obtained by stereotactic biopsy in the majority of cases. The prognosis appears dismal despite an intensive multidisciplinary therapeutic approach.

Favourable outcome of a brain trauma patient despite bilateral loss of cortical somatosensory evoked potential during thiopental sedation

We would like to present an observation that somewhat questions the predictive value of somatosensory evoked potentials on the outcome of brain trauma patients treated with thiopental coma.1,2nnA 30 year old woman suffered a high velocity car accident resulting in a diffuse brain injury. Her Glasgow coma scale score on admission was E2V2M5 (9/15), with preserved pupillary reflexes and gross motor function. Computed tomography of the head showed a traumatic disjunction of the lambdoid suture and multiple left frontobasal and temporal cerebral contusions. The patient was sedated with propofol, intubated, and monitored for intracerebral pressure (ICP) through an external ventricular drain. Her clinical condition rapidly worsened because of brain swelling around the contusions, and cerebrospinal fluid drainage, manitol boluses, and mild hyperventilation were …